Monkeypox, stigma and public health

In its “2022 Monkeypox Outbreak: Global Trends” update of October 3, 2022, the World Health Organization (WHO) has reported 68,265 laboratory confirmed monkeypox (MPX) cases in 106 states worldwide, of which 24,735 in the WHO Europe region and 42,560 in the WHO Americas region. Most laboratory confirmed cases have occurred in the United States (n = 25,434), Brazil (n = 7687), Spain (n = 7188), France (n = 3999), the United Kingdom (n = 3635) and Germany (n = 3625). Among cases for which data was available, 97.5% occurred in persons identifying as male, and 89.9% in persons identifying as gay, bisexual or other men who have sex with men. For 87.2% of cases for which data was available, transmission in the context of sexual intercourse was presumed. For 49.2% of cases for which such data was available, HIV was reported as a comorbidity of MPX.¹

The finding that gay, bisexual and other men who have sex with men are at present by far the group most affected by MPX infections has been affirmed by other epidemiological studies. In the largest study published so far, Thornhill et al. (2022) have analyzed 528 confirmed MPX infection cases from 16 countries diagnosed between April 27 and June 24, 2022, of which 84 occurred in the Americas and 444 in Europe, Israel and Australia. Of the 528 persons with MPX, 527 identified as men, 96% as gay and 2% as bisexual. For 41.0% of patients, HIV was reported as a comorbidity, and for 23% of patients for whom such data was available, gonorrhea, chlamydia or syphilis have been reported as co-infections. As reported by the clinician, sexual contact was the suspected means of transmission in 95% of cases. 103 of the 528 persons with MPX had attended large gatherings (e.g., Pride events) before diagnosis. 169 persons reported to have attended sex-on-site venues and 106 to have engaged in “chemsex” (i.e., sex under drug influence) in the month before diagnosis.² Tarín-Vicente et al. (2022) have found that anal-receptive sex is associated with significantly higher levels of MPX-caused proctitis, and oral-receptive sex with higher levels of MPX-caused tonsillitis.³

In line with these findings, much of the international and European outbreak response has so far focused on the group of gay, bisexual and other men who have sex with men. The WHO has issued special “public health advice for gay, bisexual and other men who have sex with men” already on May 25, 2022, followed by the European Centre for Disease Prevention and Control (ECDC) on June 10, 2022. The WHO Monkeypox IHR Emergency Committee has called for response actions to stop human-to-human transmission, including contact tracing and tailored vaccination campaigns, with a priority focus on gay, bisexual and other men who have sex with men.

However, we fear that too little consideration has so far been given by public health experts and policymakers to the sociopolitical dimensions of the MPX outbreak. Guidance from the WHO on risk communication to address MPX-related stigma and discrimination primarily provides language recommendations and does not address the problem of structural LGBTQI+ discrimination and health inequality. In response to stigma concerns, the WHO announced on June 14, 2022 that they would consider renaming the monkeypox disease. However, this change is challenging in light of the rules under the International Code of Virus Classification and Nomenclature (ICVCN), which lists stability as one of the essential principles of virus nomenclature. As a consequence, the WHO has so far only announced the renaming of the monkeypox virus variants from Congo Basin (Central African) clade to Clade I and from West African clade to Clade II on August 12, 2022.

Two sociopolitical dimensions of the MPX outbreak are of particular concern. First, there is a clear risk that the (global) MPX outbreak response will be undermined by hostile attitudes by politicians and societies against LGBTQI+ persons in many countries.⁴ The right of LGBTQI+ persons to be able to access tailored and evidence-based information on sexual and reproductive health has repeatedly been recognized by United Nations human rights bodies. In far too many parts of the world, however, this right is denied to LGBTQI+ persons, because speech on same-sex love and gender identity is criminalized and hate crime against LGBTQI+ persons and organizations is not prevented nor prosecuted. The devastating impact of LGBTQI+ hostility on public health has been evidenced by the initial response to the AIDS pandemic in the 1980s: It took more than four years after the first case reports had been published until then US President Ronald Reagan and the WHO recognized the threat which the disease presented to global public health. By that time, more than 10,000 persons had died from AIDS in the US alone.⁵

Second, there is a clear risk that the MPX outbreak leads to increasing discrimination against and stigmatization of gay and bisexual men and, more generally, of the LGBTQI+ community as a whole. Misconceptions of MPX by the public as a disease exclusively spread through same-sex sexual intercourse, as was the case with AIDS (which was initially labeled as “gay-related immune deficiency (GRID)”, “gay cancer” or “gay plague”⁶), can potentially reinforce discriminatory stereotypes of gay and bisexual men as “promiscuous” and “predatory”. It is likely that increased stigmatization will exacerbate health and economic inequalities suffered by gay and bisexual men and jeopardize efforts to combat MPX. In this sense, UNAIDS has warned that “[s]tigma and discrimination undermine epidemic response, sending people with symptoms underground and failing to address the underlying barriers that people face in attempting to protect their own health and that of their community”.⁷

In addition, there is a clear risk of abuse of the MPX outbreak for political purposes. In Latvia, right-wing lawmakers have (ultimately unsuccessfully) tried to ban the 2022 Pride event in the capital Riga.⁸ In Iraq, the parliament is currently considering a draft bill which would criminalize same-sex sexual intercourse and “ban LGBT+ identities”, after the most influential cleric of the country has called MPX the “outcome of homosexual behaviour” in May 2022.⁹ In the United States, Republican congresswoman Marjorie Taylor Greene has recently pretended that MPX infections in children were due to sexual child abuse to support her narrative that opponents of anti-LGBT+ legislation (like the recent “Don't Say Gay” bill in Florida) are “pro-child predators”.¹⁰

In sum, we see a clear need to raise awareness of public health experts and policymakers of the sociopolitical implications of the MPX outbreak for gay, bisexual and other men who have sex with men and, more generally, the LGBTQI+ community as a whole. To this purpose, we have developed policy recommendations in Table 1 for a holistic response to address the MPX outbreak within a broader policy framework to promote LGBTQI+ (health) equality.

Table 1.

Policy recommendations to promote LGBTQI+ (health) equality in the MPX outbreak response.

•Continuous, evidence-based review of the ethical, legal and social implications of MPX outbreak response measures; •Community involvement in processes to develop MPX outbreak response measures; funding and institutional support for community-based outbreak response strategies and peer-to-peer communication and support on MPX; •Continuous, evidence-based and non-discriminatory communication and information on MPX to the general public; tailored information and communication to risk groups (e.g., gay, bisexual and other men who have sex with men); renaming of the monkeypox disease in the ICD-11; clarification that MPX is not limited to gay, bisexual and other men who have sex with men and can also be transmitted through different-sex sexual intercourse and non-sexual means of transmission (e.g., close skin contact); •Development and public funding of clinical, public health and bioethics research on MPX; in particular of research which clarifies the transmission mode and factors for susceptibility to (severe) infection, investigates the reasons for higher MPX incidence in gay, bisexual and other men who have sex with men, and lays out possibilities of prevention of MPX infections; •Development of a comprehensive global action plan to promote LGBTQI+ health equality (e.g., by the WHO or, transitionally, by the United Nations Independent Expert on sexual orientation and gender identity); •Development of comprehensive national action plans to implement the WHO Global Health Sector Strategies (GHSS) on HIV, viral hepatitis and STIs (as relatively frequent comorbidities of MPX), and the WHO consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations; •Adoption of anti-discrimination policies and of national strategies to promote LGBTQI+ inclusivity and open communication on LGBTQI+ health topics, inter alia, in public health authorities, medical and public health schools, and research institutions; integration of training on LGBTQI+ health topics and communication with traditionally marginalized groups into medical and public health school curricula; development of mechanisms (e.g., an ombudsperson system) to address cases of LGBTQI+ discrimination in healthcare; •Development of (compulsory) education and training programs and settings for open communication on LGBTQI+ health topics and sexual health topics for public health experts, researchers and policymakers.

Contributors

The work has been conceived and designed by the three authors. JWM: initiation of the work; acquisition and analysis of pertinent literature; drafting and writing of the article; SH: critical review of the outline and of the final article; NBA: critical revision of the project plan and the outline; critical review of the final article.

Declaration of interests

There are no competing interests to declare.